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Objective: To audit the medical record documentation of patients admitted to a medical unit in year 2005
at a teaching hospital NWFP Pakistan.
Material and Methods: The retrospective audit was conducted in the Medical "C" Unit of Government
Lady Reading Hospital Peshawar from 1st January 2005 to 31st December 2005. Out of 3944 patients
admitted during 2005, 200 case notes were randomly selected and subjected to audit. The clinical notes
were broadly analysed for documentation of six parameters. Each parameter's documentation was to be
graded as very good, good, average, poor, or not documented.
Results: Personal bio-data was documented good in 194(97%) cases; history and examination were good
in 22 (11%) cases; diagnosis was very good in 48 (24%) cases; Investigation were documented very good
in 18 (9%) cases and good in 134 (67%) cases; Progress notes were good in 156 (78%) cases and
treatment was documented good in 186 (93%) cases. In 82 (41%) charts, one or more of the six selected
items were not documented at all. Investigations were not written in 20%, progress notes in 12%, history
and examination in 9%, diagnosis in 6%, treatment in 3% and bio-data in 1% of the case notes
Conclusion: Documentation of important clinical information is poor even in the hospital charts of
patients admitted in tertiary care hospital. Poor documentation in medical records might reduce the quality
of care and undermine analyses based on retrospective chart reviews.
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